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APSIC Abstracts on Antimicrobial Stewardship

Feb 24, 2017

The following abstracts on the topic of antimicrobial stewardship are from the meeting of the eighth International Congress of the Asia Pacific Society of Infection Control (APSIC), held in Bangkok, Thailand, Feb. 12-15, 2017.

AS1: Antibiotic associated diarrhea in Indian hospitals: common or commonly missed?

Dorairajan Sureshkumar, Kalyanaraman Supraja, Soundararajan Sharmila

Background
Most of the antibiotic stewardship programs (ASP) in the developing world measure antibiotic consumption, adherence to antibiotic guidelines and antibiotic resistance. However, antibiotic associated diarrhea (AAD) is a common medical problem of antibiotic treatment and important quality monitor of ASP was not monitored commonly in India. This study aimed to measure the prevalence of AAD in hospitalized patients receiving antibiotics.

Materials and methods
A point prevalence study was conducted in a 300-bed tertiary care cardiac hospital in Chennai, South India. All hospitalized patients in cardiology wards and intensive care units (ICUs) receiving at least one dose of either oral or intravenous antibiotic were audited by physician assistant for the symptoms of diarrhea and cross checked by interviewing patients.

Results
During the study period, 107 eligible patients had available records for analysis. There were 58 patients (54.20%) receiving antibiotics. Of these, there were 34 receiving single antibiotic, 17 receiving two antibiotic combinations, 4 receiving three antibiotic combinations and 3 were taking four antibiotic combinations. The details of diarrhea was missing in 3 patients’ medical records. Only 2 patients (3.44%) developed diarrhea and they received two antibiotics combination.

Conclusions
Although more than half of the patients received antibiotics, AAD was not common in our hospital. However, regular monitoring of AAD along with other parameters were required for better implementation of ASP in the hospital.

AS2: Antibiotic prescription after restricted antimicrobial program

Cucunawangsih Cucunawangsih, Benny Setiawan, Nicolaski Lumbuun

Background
Infections caused by antibiotic-resistant bacteria have led to increase burden on the healthcare system. Effective antimicrobial stewardship control program (ASCP) requires the clinician acceptance of program recommendation. We evaluate the antibiotic consumption and antibiotic susceptibility after ASCP implementation in 2013 in a teaching hospital in Tangerang, Indonesia.

Materials and methods
Our ASCP restrict the prescription of carbapenems, fourth generation cephalosporins, and tigecycline. Antibioticsusceptibility and consumption of restricted antibiotics were extracted from database. Antibiotics use was measured by the number of DDDs per 100 bed-days

Results
The proportion of susceptible bacteria against; cefpirome increased from 57% to 73%, cefepime 63% to 64%, imipenem 78% to 83%, and tigecycline 74% to 75% during 2013 to 2015. The proportion of meropenem susceptibility remained the same at 70% in 2013 and 2015. The defined daily doses (DDDs) per 100 bed-days was significantly reduced in all restricted antibiotics from 2013 to 2015 except tigecycline. The consumption of 1.0 g cefepime was 2190, 1035 and 107, 1.0 g cefpirome was 313, 473 and 140, 1.0 g meropenem was 16047, 11271 and 5281, 0.05 g teicoplanin was 40.4, 58.8 and 0, 0.5 g vancomycin was 716, 731 and 212.5, and 0.6 g linezolid was 129.6, 72 and 0 in 2013, 2014 and 2015, respectively

Background
Infection with antibiotic-resistant bacteria results in increased morbidity, mortality and economic burden. Antimicrobial stewardship program (ASP) has been widely implemented to guide appropriate antibiotic use, in order to minimize antibiotic resistance. However, establishment of ASP is not always possible due to lack of interest. We examined the application of diagnosis-procedure combination (DPC) data as an incentive for achieving the target of ASP.

Materials and methods
The Toho University Ohashi Medical Center inpatient initiated ASP focusing on reduction of inappropriate perioperative antibiotics and anti-MRSA drugs. The DPC data was extracted for antibiotic consumption and duration in each patient from April 2013 to March 2016.

Results
The consumption of the first-generation and second-generation cephalosporins as perioperative antimicrobial agents was 62% during observation period. This proportion was below the initial benchmark. On the other hand, the consumption of anti-MRSA agents was 2.26% higher than the benchmark. More than half of patients undergoing surgery received perioperative antibiotics only one day. The majority was cardiovascular surgery patients used intraoperatively.

Conclusions
Our study shows that utilization of the DPC database for advancing the ASP is possible. It is convenient process to measure outcome of ASP at the group or organizational level.

Background
Manila Doctors Hospital (MDH), a tertiary hospital in the Philippines had initiated antimicrobial stewardship (AMS) to reduce antimicrobial resistance(AMR) in the institution. The impact of AMS on prescribing practices of physicians, antibiotic utilization and rates of multiple drug resistant organisms (MDROs) were evaluated.

Materials and methods
From 2011 to 2013, a multi-disciplinary AMS team initiated educational campaigns, developed AMS policies and antimicrobial guidelines based on the local antibiogram. Pilot implementation of policies was conducted in 2014 to 2016. Outcome measures included compliance rate of physicians to the surgical prophylaxis guideline, utilization of carbapenems and vancomycin in defined daily doses (DDDs per 100 patient-days) and rates of multi-drug resistant organisms.

Results
The utilization of carbapenems was 47.48, and 31.72 DDDs/100 patient days in 2014 and 2015, respectively (33% reduction). The utilization of vancomycin increased from 3.76 DDDs/100 patient-days in 2014 to 4.93 DDDs/100 patient-days in 2015. There was increased compliance to timing of surgical prophylaxis from 53% in 2014 to 89% in 2016. The proportion of Methicillin-resistant S. aureus (MRSA) decreased from 60% in 2013 to 47% in 2015. The proportion of Extended spectrum beta-lactamase (ESBL)-producing K. pneumoniae decreased from 12% in 2013 to 10% in 2015, whereas proportion of ESBL-producing E. coli increased from 11% in 2013, to 20% in 2014, and 23% in 2015. The proportion of Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae was 16% in 2013, 23% in 2014, and 16% in 2015.

Conclusions
The AMS program resulted in increased compliance to the surgical prophylaxis policy, decreased utilization of carbapenems, and decreased proportion of MRSA, ESBL-producing K. pneumoniae. There is a room for improvement in reduction vancomycin use in this setting.

Background
Extensively drug-resistant Acinetobacter calcoaceticus-baumannii complex (XDR-ABc) pneumonia is an important cause of healthcare-associated pneumonia. Although tigecycline was not approved for treatment of healthcare-associated pneumonia, it has been used off-label for XDR-ABc pneumonia. We evaluated whether the clinical efficacy of tigecycline combined with aerosolized colistin methanesulfonate (CMS) is superior to aerosolized CMS alone.

Materials and methods
This is a retrospective case-control study, conducted in Wan-Fang Medical Center, Taipei Medical University, Taipei, Taiwan from November 2014 to February 2015. The definition of XDR-ABc pneumonia was pneumonia caused by ABc with susceptibility only to colistin and tigecycline. Cases were patients who received aerosolized CMS in combination with intravenous tigecycline for at least 5 days to treat XDR-ABc pneumonia. Controls were those who received inhaled CMS alone and were selected based on the following matching criteria to cases; age (±5 years), Acute Physiology and Chronic Health Evaluation (APACHE) II score (±4 points).

Results
There were 53 patients in each group. The mean age of patients was 80 years old. The proportion of patients underwent mechanical ventilation were 35.8% and 28.3% in cases and controls, respectively (p = 0.45). The median APACHE II score was 17.5 (15.3-19.6) in cases and 17.3 (15.3-19.2) in control group (p = 0.9). The mean length of hospital stay was 32 days (p = 0.524), 30-days mortality rate was 34% and 22.6%(p = 0.02), and overall mortality was 46.2% and 33.3% (p = 0.19)in cases and controls, respectively.

Background
In 2013, the amount of antibiotics in this medical center accounted for 8.4% of its total drug amount. The calculated DID dosage of inpatient antibiotics was 917 and the rate of antibiotic-resistant strains has been on the rise. To cope with the development of drug resistance, from 2014 to 2015, the Antibiotic Stewardship Program (ASP) was executed to promote proper use and therefore to decrease the volume of antibiotics, and to reinforce MDRO isolation.

Materials and methods
A multi-discipline team for antibiotic stewardship was reformed. ID doctors and infection control practitioners developed regulations for antibiotic use, conducted training programs, reviewed antibiotic uses and gave feedback. The compliance and accuracy of hand hygiene, and isolation precaution and protection were strengthened by nursing personnel. The pharmacist team division provided daily antibiotic assessment and statistics. Microbiology laboratory was responsible for drug-resistant data.

Results
The expenditure of consumed antibiotic, as a ratio of total drug, declined from 8.4% in 2013 to 5.6% in 2015. From 2013 to 2015, the DID from 917 to 824, carbapenems from 53.4 to 47.4, quinolones from 95.6 to 81.9, and glycopeptides from 28.4 to 21.9. Furthermore, CRPA from 16.7% to 5.7%, CRAB from 55.7% to 26.2%, MRSA from 52.2% to 43.5%, VRE from 60% to 45%. However, a little elevation of CRKP from 9.62% to 11.3% was observed.

Conclusions
Employing ASP, we have enhanced the cooperation among antibiotic team members. As a result, the correct use of antibiotics was improved, the amount of antibiotics was less consumed, and the ratios of most MDRO declined.

Background
Increased antibiotic resistance among Escherichia coli has led to inappropriate empirical antibiotic use (IAU) for associated infections. Limited data exists for IAU among cases with acute uncomplicated cystitis (AUC).

Material and methods
We conducted a prospective observational study at a General Practice (GP) Clinic from December 2014 to February 2016. Eligible participants included women aged 15-60 years with AUC. All participants’ urine cultures were sent before empirical antibiotics were prescribed at the GP physicians’ discretion. The rate of IAU was subsequently identified by the investigators. Strategies to minimize IAU were then determined based on the relevant data of AUC treatment in this study.

Results
Eighty participants were enrolled. E. coli was the most common pathogen isolated (78.3%) with resistance rates to trimethoprim-sulfamethoxazole, fluoroquinolone, ceftriaxone, amoxicillin-clavulanate and ertapenemof61.7%, 42.6%, 21.3%, 2.1% and 0%, respectively. Extended-beta-lactamase production was confirmed in 12.5% of E. coli isolates. The rate of IAU was 91.3%. Ciprofloxacin use was the only independent risk factor for IAU (adjusted odds ratio, 6.471; 1.089-38.461; P =0.04). Based on the study results, including the in-vitro susceptibility data and the risk factors for acquisition of antibiotic-resistant E.coli, a specific algorithm for AUC treatment was created. If this algorithm was used along with education about IAU and antibiotic stewardship program focusing on ciprofloxacin use, the rate of IAU would have decreased to 3.8%.

Conclusions
Our findings suggest the high rate of IAU in AUC treatment in a GP setting and underlie the need for multifaceted interventions to reduce IAU.

AS9: Synergy between antimicrobial stewardship programs and infection control efforts

Material and methods
Our study objectives were to define areas of synergy between IC and ASP efforts with specific examples and to determine how best to promote these. Bryn Mawr Hospital: 250-bed community-teaching hospital with 3 IC practitioners; ASP team has one infectious diseases (ID) physician and an ID-trained Pharm.D. It is part of a 5 hospital system with microbiology laboratory. ASP has been in placed for 5-1/2 years. Synergy between ASP and IC: (1) collaborative identification of outbreaks (e.g., regional babesiosis in 2015, ongoing C. difficile cases), (2) monitoring antimicrobial resistance via complementary computer surveillance systems, (3) coordinating presentation of microbiology antibiograms, (4) collaboration on healthcare staff educational programs, and (5) joint presentations to system wide committees and accrediting organizations.

Results
From 2011 to 2015 dosage days for selected antibiotics decreased 58-90% per 1000 patient-days and total antibiotic cost decreased $577,680 (54%) per year.

Conclusions
IC and ASP programs should work together to the benefit of both and the institution and health system as a whole. This can be facilitated by regular communications and meetings, ongoing review of microbiological pathogen and susceptibility trends, and collaboration on research and educational programs.

Background
Healthcare workers (HCWs) play an important role to be a consultant about antibiotic use for patients. This would be helpful to reduce antibiotic overuse and prevent emergence of antimicrobial resistance in the hospital and public settings.

Materials and methods
We conducted across sectional study by using a self-assessment validated questionnaires, to determine current awareness and common habits related to antibiotic usage and antimicrobial resistance among HCWs in Hung Vuong hospital; an obstetrics and gynecology hospital in Vietnam.

Results
A total of 161 HCWs were enrolled in the survey. Although 99% of HCWs responded correctly "Many infections are becoming increasingly resistant to treatment by antibiotics", 77% of them thought that “antibiotic resistance occurs when your body becomes resistant to antibiotics”. A total of 19% (95% CI: 0.13 – 0.26) and 8% (95% CI: 0.04 – 0.13) of HCWs have correct knowledge about antibiotic usage and antimicrobial resistance. A total of 16% of HCWs answered that they have to prescribe antibiotic because they cannot follow up the patients' condition. Twenty-two percent of HCWs answered that it is necessary to take antibiotic when people have fever.

Conclusions
Majority of HCWs have incorrectly awareness about definition of antibiotic resistance. Furthermore, their habit of antibiotic use is inappropriate. We should have intervention programs to improve HCWs’ knowledge and control their antibiotic usage.

Background
It is necessary to understand on the prevalence of hospital acquired infections and carbapenem-resistant gram negative bacteria (CR-GNB) in children’s hospital in resource constrained settings.

Material and methods
During a 1-year study period (2012-2013), we conducted a monthly point prevalence surveys (PPS) using the protocol of ECDC in 2 major Vietnamese children’s hospitals and 3 referral hospitals with pediatric intensive care units (PICU).

Results
1363 cases were included in the PPS. Average age was 11 months (median 3 months). Major reasons for admission were infection 66%. Admission source was other hospital 49.3%, current hospital 36.5%. Intubation 47.8%, CVC 29.4%, PVC 86.2%. HAI prevalence was 33.1%, of these 2 HAI in 9.9% and 3 HAI in 1.3%. Intubation had a significant (p < 0.001) correlation with HAI. The most common diagnosis was pneumonia 52.2%, sepsis 26.4%, the SSI and NE 9 cases (2%) each. Positive laboratory findings were 212 (43%). Carbapenem resistance were 40%; 46% of K. pneumoniae were carbapenem-resistant and 76% cephalosporin-resistant. 56% of P. aeruginosa and 64% of A. baumannii were carbapenem-resistant; 78% of S. aureus were MRSA. Antibiotics were given to 1307 (88.6%), one antibiotic 39.9%, 2 antibiotics 44.7%, 3 antibiotics 10.6% and 4 antibiotics 0.8%, average 1.7 antibiotics per case. Colistin was given to 97 cases, of these 49% had reported carbapenem-resistant strains; 49% carbapenem-resistant cases were treated with colistin.

Conclusions
There is a high prevalence of HAI in Vietnamese PICUs, usually caused by GNB with a very high antibiotic resistant rate. Colistin is commonly used in combination with other antibiotics to treat these resistant infections.